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Deaths from AIDS

The human toll and suffering due to HIV & AIDS is already enormous. AIDS is now by far the leading cause of death in sub-Saharan Africa. Since the beginning of the epidemic over 15 million Africans have died from AIDS. During 2004 an estimated 2.3 million adults and children died as a result of AIDS in sub-Saharan Africa.

The Impact of HIV/AIDS in Africa

Many countries in sub-Saharan Africa have failed to bring the epidemic under control. Nearly two-thirds of the world's HIV-positive people live in sub-Saharan Africa, although this region contains little more than 10% of the world's population. There is a significant risk that some countries will be locked in a vicious cycle, as the number of people falling ill and subsequently dying from AIDS has a tremendous impact on many parts of African society, including demographic, household, health sector, educational, workplaces and economic aspects.

The Impact on the Health Sector

In all affected countries the HIV/AIDS epidemic is bringing additional pressure to bear on the health sector. As the epidemic matures, the demand for care for those living with HIV/AIDS rises, as does the toll among health workers. In sub-Saharan Africa, the annual direct medical costs of AIDS (excluding antiretroviral therapy) have been estimated at about US$30 per capita, at a time when overall public health spending is less that US$10 for most African Countries.

Health-care services face different levels of strain, depending on the number of people who seek services, the nature of their need, and the capacity to deliver that care.

The Effect on Hospitals

As HIV infection progresses to AIDS, there is an increase in total hospitalisations. The 2001 Swaziland Human Development Report estimated that people living with HIV/AIDS occupied half of the beds in some health care centres in Swaziland. HIV prevalence among hospitalised patients was almost 33% in one Tanzanian hospital, making HIV infection the major cause of illness leading to hospitalisation. Without major interventions, the problem will worsen. The World Bank estimates that the number of hospital beds needed for AIDS patients could exceed the total number of beds available in Swaziland by 2004 and in Namibia by 2005.¹

The HIV/AIDS epidemic is also having a negative impact on the overall quality of care provided in hospitals. A shortage of beds, for example, means that people tend to be admitted only at the later stages of illness, reducing their chances of recovery, as some Kenyan hospitals have discovered. Lengthy hospital stays are being reported in Botswana's hospitals, along with staff shortages and staff burnout. Also, more time has to be spent diagnosing cases that are more complex as the epidemic deepens.

Health Care Workers

At the same time as the demand for health services is expanding, so more-health care professionals are being affected by HIV/AIDS. For example, Malawi and Zambia are experiencing a 5-6 fold increase in health worker illness and death rates. Increased workloads and stress might may also spur emigration by health professionals.

The antiretroviral programme in Botswana has faced an acute shortage of trained staff, which has had a significant effect on the programme. There are not enough trained staff to carry out the health checks required for enrolment on the programme, and this has contributed to the enrolment and treatment rates being lower than was first hoped. The problem is compounded by the fact that over 90% of the doctors are foreign and do not speak Setswana, the local language. Another problem faced when recruiting health care staff from abroad is that it takes time for them to become familiar with the local culture.²

Community/Home-Based Care

The emergence of community-bases care programmes, often organised by people living with HIV/AIDS, has become one of the outstanding features of the epidemic. They are also playing a key role in easing the impact. Although many of these programmes are operated by religious groups or non-governmental organisations, the effectiveness of the care does depend on support from formal health, welfare and other social sectors. Also, a study in South Africa has suggested that while home-based care is not cheap it is still an affordable option for the care of people with HIV/AIDS.

The Impact on Households

The toll of HIV/AIDS on households can be very severe. Although no part of the population is unaffected by HIV, it is often the poorest that are the most vulnerable to HIV/AIDS and on whom the consequences are most severe. In many cases, the presence of AIDS means that the household will dissolve, as parents die and children are sent to relatives for care and upbringing. A study in Zambia revealed that 65% of households in which the mother had died had dissolved. But much happens to a family before this dissolution happens: HIV/AIDS strips the family of assets and income-earners, further impoverishing the poor.

Household Income

A study in Côte d' Ivoire revealed that income in affected households was half that of the average household income. This was often the result not only of the loss of income due to illness among household members, but also because other members had to divert more time and effort away from income-generating activities.³

Household Income

A study in three countries, Burkina Faso, Rwanda and Uganda, has calculated that AIDS will not only reverse efforts to reduce poverty, but will increase the percentage of people living in extreme poverty (from 45% in 2000 to 51% in 2015). In Botswana, household income for the poorest quarter of households is expected to fall by 13%. Income earners in these households are also expected to take on an average of four more dependants because of HIV/AIDS.

Basic Necessities

A study in South Africa found that already poor households coping with an AIDS-sick member were reducing spending on necessities even further. The most likely expenses to be cut were clothing (21%), electricity (16%) and other services (9%). Falling incomes forced about 6% of households to reduce the amount they spent on food and almost half of households reported having insufficient food at times.⁴

"She then led me to the kitchen and showed me empty buckets of food and said they had nothing to eat that day just like other days" ⁴

Food Production

It is estimated that in Burkina Faso, 20% of rural families have reduced their agricultural work or even abandoned their farms because of AIDS. In Ethiopia, AIDS-affected households were found to spend 11-16 hours per week performing agricultural work, compared with an average 33 hours for non-AIDS affected households.

Illness

Taking care of a person sick with AIDS is not only an emotional strain for household members, but also a major strain on household resources. Loss of income, additional care-related expenses, the reduced ability of caregivers to work, and mounting medical fees and funeral expenses together push affected households deeper into poverty. According to the study in Côte d' Ivoire, health care expenses rose by up to 400% when a family member had AIDS.

Funerals

But the financial burden of death can also be considerable, with some families in South Africa spending three times the total household monthly income on a funeral.

How do HIV/AIDS affected Households cope in Africa?

Three main coping strategies appear to be adopted among affected households. Savings are used up or assets sold; assistance is received from other households; and the composition of households tends to change, with fewer adults of prime working age in the households.

Almost invariable, the burden of coping rests on women, as there is an increased demand for their income-earning labour, household work, childcare and care of the sick. As men fall ill, women often have to step into their roles outside the homes. In parts of Zimbabwe, for example, women are moving into the traditionally male-dominated carpentry-industry. This often results in women having less time to prepare food and for other tasks at home.

"I used to stay with the children, but now it is a problem. I have to work in the fields. Last year I had more money to hire labour so the crops got weeded more often. This year I had to do it myself."
- Angelina, Zimbabwe.⁵

Tapping into savings if available and taking on more debt is usually the first option by households that struggle to pay for medical treatment or funeral costs. Then as debts mount, precious assets, such as bicycles, livestock and even land, are sold. Once households are stripped of their productive assets, the chances of them recovering and rebuilding their livelihoods become even slimmer.

The number of working adults in a family will often decrease.

"The first problem with this family is that no one is working. There is no food and no clothes, her mum is not working and there is no father."
- Nosipho, South Africa.⁶

One of the more unfortunate responses to a death in poorer households is removing the children (especially girls) from schools. Often the school uniforms and fees become unaffordable for the families and the child's labour and income-generating potential are required in the household.

"Her brother is sixteen, he is also not in school, he is looking after someone else's cattle for little money. The last born girl has been taken by another pensioner who is not a relative, they see her on holidays."
- Nosipho, South Africa.⁶

The Impact on Children

It is hard to overemphasise the trauma and hardship that children affected by HIV/AIDS are forced to bear worldwide. Not only does HIV/AIDS mean children lose their parents or guardians, but sometimes it means they lose their childhood as well.⁷

As parents and family members become ill, children take on more responsibility to earn an income, produce food and care for family members. It is harder for these children to access adequate nutrition, basic health care, housing and clothing. Fewer families have the money to send their children to school.

Often both of the parents are HIV-positive in Africa. This has resulted that more children have been orphaned by AIDS in Africa than anywhere else. Also many children will be part of a generation of to be raised by their grandparents or left their own in child-headed households. As projections of the number of AIDS orphans rise, some calls have been heard for an increase in institutional care for children. This solution is not only expensive but also detrimental to the children. Institutionalisation stores up problems for society, which is ill equipped to cope with an influx of young adults who have not been socialised in the community in which they have to live. There are other alternatives available. An example is the approach developed by church groups in Zimbabwe, where they recruit community members to visit orphans in their homes where they live either with foster parents, grandparents, other relatives or in child-headed households.

The way forward is prevention. It is important to prevent children from becoming infected with HIV at birth and later on in their life. Also, generally preventing more people from becoming infected with HIV in the future, and care to prevent people from dying of AIDS is essential. Then fewer children will be orphaned by HIV/AIDS.

The Impact on Education Sector

The extent to which schools and other education institutions are able to continue functioning (as part of the essential infrastructure of societies and communities) will influence how well societies eventually recover from the epidemic.

Fewer Children will Receive a Basic Education

A decline in school enrolment is one of the most visible effects of the epidemic. This will in itself have an effect on HIV prevention, as a good basic education ranks among the most effective and cost-effective means of preventing HIV.⁸

"Without education, AIDS will continue its rampant spread. With AIDS out of control, education will be out of reach"
- Peter Piot, Director of UNAIDS.⁹

This reduction in the number of children attending school, will have a significant impact on the ability of many countries to achieve the Education For All targets.¹⁰

Why are Fewer Children Attending School in Africa?

Contributing factors include:

• The removal of children from school to care for parents and family members
• An inability to afford school fees and other expenses
• AIDS-related infertility and a decline in birth rate, leading to fewer children
• More children are themselves infected and either do not live long enough to start school or do not survive the years of schooling.

For example, research in South Africa showed that the number of pupils enrolling in the first year of primary school in 2001 in parts of KwaZulu-Natal Province, was 20% lower than in 1998. In the Central African Republic and Swaziland, school enrolment is reported to have fallen by 20-36% due to AIDS and orphanhood, with girls being most affected.

"If there is a shortage of money the girl child stays behind and the boy child goes to school. Even if a girl is more intelligent." ¹¹

The Impact on Teachers

HIV/AIDS does not only affect pupils but teachers as well. A study in Zimbabwe found that 19% of male teachers and almost 29% of female teachers were infected with HIV. In 2004, it is estimated that 17% of Mozambique's teachers are HIV-positive. This is considerably higher than the national average of 13% HIV prevalence among people aged 15 and 49. It is believed that this will lead to the death of 1.6% per year of the country's teachers.¹²

Teacher absenteeism is increased by HIV/AIDS as the illness itself causes increasing periods of absence from class. Teachers with sick families also take time off to attend funerals or to care for sick or dying relatives and teacher absenteeism also results from the psychological effect of the epidemic.¹³

When a teacher falls ill, the class may be taken on by another teacher, may be combined with another class or left untaught. But even when there is a sufficient supply of teachers to replace losses, there can be a significant impact on the students.

"Some of the schools have lost teachers due to this disease. Eventually after a year or two they are replaced with another teacher. But they are not the same as the ones who have died. They cannot teach or do the work as well as the one affected by AIDS. And also the learners, the learners used to know their teachers very well."
- School principal, Namibia.¹⁴

The illness or death of teachers is especially devastating in rural areas where schools depend heavily on one or two teachers. Moreover, skilled teachers are not easily replaced. Swaziland has estimated that it will have to train 13,000 teachers over the next 17 years, just to keep services at their 1997 levels - 7000 more than it would have to train if there where no AIDS deaths.

The Impact on Enterprises and Workplaces

HIV/AIDS dramatically affects labour, setting back economic activity and social progress. The vast majority of people living with HIV/AIDS in Africa are between the ages of 15 and 49 - in the prime of their working lives.

AIDS weakens economic activity by squeezing productivity, adding costs, diverting productive resources, and depleting skills. Also, as the impact of HIV/AIDS on households grows more severe, market demand for products and services can fall. The epidemic hits productivity through increased absenteeism. Comparative studies of East African businesses have shown that absenteeism can account for as much as 25-54% of company costs.

A study in several southern African countries has estimated that the combined impact of AIDS-related absenteeism, productivity declines, health-care expenditures, and recruitment and training expenses could cut profits by at least 6-8%. NamWater, Namibia's largest water purification company, has reported that HIV/AIDS was hindering its operation as absenteeism rose and productivity dropped. A study of a sugar mill in South Africa put the cost per worker per year at R9,500 (about £800). Of this, the cost of replacement workers, lost productivity, and absenteeism account for about a quarter each.¹⁵

Company costs for health-care, funeral benefits and pension fund commitments are likely to rise unexpectedly as early retirement and deaths rise. A study of a commercial agricultural estate in Kenya showed that AIDS-related medical expenditure exceeded projected expenses by 400%. Funeral costs are also provided by a number of employers in Africa and they are rising sharply.

As HIV/AIDS related costs have risen, so more and more employers have set up HIV/AIDS related programmes at their workplaces. These programmes work more effectively when they also consider the wider realities of the workers' lives. An example is the gold-mining districts in South Africa. The gold mines attract thousands of workers, often from poor and remote regions. Most live in hostels, separated from their families and as a result a thriving sex industry operates around many mines and high HIV prevalence is common. In recent years, mining companies have been working with a number of organisations to implement prevention programmes for the miners. These have included mass distribution of condoms, medical care and treatment for sexually transmitted diseases and awareness campaigns. However, work and social conditions make it difficult to achieve and sustain reductions in HIV and other sexually transmitted infection levels.

In Swaziland, an employers' anti-AIDS coalition has been set up to promote voluntary counselling and testing. The coalition not only includes larger companies but also small and -medium -size enterprises. In Botswana, the Debswana diamond company offers all employees HIV testing, and if they are HIV positive, they and their spouses are offered HIV antiretroviral drugs.¹⁶ This policy was introduced in 1999 when the company found that many of their work force were HIV positive. With a skilled workforce, it is financially worth their while to protect the health and therefore the productivity of their workers. They also discovered that retirements due to ill health and AIDS-related deaths had risen markedly. In 1996, 40% of retirements and 37.5% of deaths were due to HIV/AIDS. By 1999, the proportion had risen to 75% and 59% respectively.¹⁶

The Impact on Life Expectancy

In many countries of sub-Saharan Africa, AIDS is erasing decades of progress in extending life expectancy. Life expectancy reflects the conditions in a community, but also life expectancy affects conditions in the community. Average life expectancy in sub-Saharan Africa is now 47 years, when it would have been 62 years without AIDS. Life expectancy at birth in Botswana has dropped to a level not seen in Botswana since before 1950. In less than ten years time, many countries in Southern Africa will see life expectancies fall to near 30, levels not seen since the end of the 19th Century.¹⁷

Average life expectancy in 11 African Countries (age in years)

By 2010, the populations of five countries - Botswana, Mozambique, Lesotho, Swaziland and South Africa will have started to shrink because of the number of people dying from AIDS. In two more countries, Zimbabwe and Namibia, the population growth rate will have slowed almost to zero.

The Economic Impact

Through its impacts on the labour force, households and enterprises, HIV/AIDS can act as a significant brake on economic growth and development. Besides the human cost, HIV/AIDS is having deep effects on Africa's economic development. In turn, this effects to Africa's ability to cope with the epidemic.¹⁸ The impact of HIV/AIDS on the economies of African countries is difficult to measure. The economies of many of the worst affected countries were already struggling with development challenges, debt and declining trade before HIV/AIDS started to affect Africa. Together with other factors, HIV/AIDS has had a devastating effect on many countries economies.

HIV/AIDS has an impact on labour supply, through increased mortality and morbidity. This is multiplied by the loss of skills in key sectors of the labour market. Long periods of AIDS-related illness reduce labour productivity. Government income also declines, as tax revenues fall, and governments are pressured to increase their spending, to deal with the rising prevalence of AIDS, as a result creating a potential financial crisis. One review reported that the annual costs associated with sickness and reduced productivity as a result of HIV/AIDS varied from US$17 per employee in Kenyan manufacturer firm to US$300 in the Ugandan Railway Corporation.¹⁹ A recent study in South Africa and Botswana found that HIV/AIDS among workers added 0.45-5.9% to the companies' annual salary and wage bills

A recent calculation has suggested that the rate of economic growth has fallen by 2-4% in sub-Saharan Africa. Meanwhile, some studies have forecast that, by 2015, the economies of Botswana and Swaziland would grow by 2.5% and 1.1% points less, respectively, than they would have in the absence of the epidemic. By the beginning of the next decade, South Africa, which represents about 40% of sub-Saharan Africa's economic output, faces a real gross domestic product 17% lower than it would have been without AIDS.

Many of the continent's economic development goals depend on Africa's ability to diversify its industrial base, expand exports and attract foreign investment. By making labour more expensive and reducing profits, AIDS limits the ability of African countries to attract industries that depend on low-cost labour and makes investments in African businesses less desirable. HIV/AIDS therefore threatens the foundations of economic development in Africa.²⁰

The Future Impact of HIV/AIDS

This page has outlined just some of the ways in which HIV/AIDS has already started to have a devastating impact on countries in Sub-Saharan Africa. But HIV/AIDS could have an even greater impact in the future as increasing numbers of people become ill and die. This is not however inevitable as much can, and indeed should be done, to reduce the impact of the epidemic.

What needs to be done, is that alongside the continuation of prevention programmes, there needs to be a major international effort to provide treatment and care for those who are becoming sick. Million of lives can be extended, at least for a few years, if there is sufficient action now. But equally millions of people will die over the next few years if there is insufficient action. The treatment and care needs to consist of a range of provision including voluntary counseling and testing services, food, treatment for Opportunistic Infections and antiretroviral treatment.

There has been a great deal of emphasis over the last year on a number of specific initiatives, the most significant of which is the President Bush Emergency Plan for AIDS Relief, And although there is now slightly more information available about what this plan is going to provide, and some money is starting to be distributed, it is still unclear how many people are going to get improved HIV/AIDS treatment as a result, and equally importantly when they will get it.

Another very important initiative is the WHO 3 by 5 initiative, launched on December 1st 2003. The 3 by 5 initiative aims to provide HIV/AIDS antiretroviral treatment for 3 million people by the end of 2005. The WHO does not have the money itself, nor does it seek to do this itself. Rather the WHO 3 by 5 plan is a "blueprint" of how such treatment could be provided. WHO will need additional money just to carry out its own role in the plan.

There is also the Global Fund for HIV/AIDS, TB and Malaria, and some of the money that they are going to be providing to the governments of different countries, will also be used to provide treatment. It is already clear that there is a major lack of coordination between these major international organizations and their differing HIV/AIDS initiatives.

With all of these initiatives, there is currently lack of urgent action. Too much time is spent on detailed planning, and on ensuring that everything is carried out to a comparable standard to those standards adopted in more developed countries, There has to be with everything a "good enough standard" adopted in order that, actions which would on other occasions take years, can instead be done in months.

Everyone has to act now, as a matter of great urgency, and to contribute in whatever way they can. And if enough people act now, the lives of millions can be saved.

Last updated January 11, 2005

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